“This is not about people being cold to one another or threatening,” Nielsen says. “It was clear that she was doing what she need to do and we were going to do what needed to do, and let the forces prevail.”

Nielsen’s tough-but-diplomatic approach will face a far bigger challenge, however, as Congress begins to grapple with how to lower costs throughout the American health care system and to expand access to cover 47 million uninsured Americans.

Nielsen’s perspective is shaped in part by her upbringing and background. The daughter of a plumber in Elkins, W.Va., she came to Washington in the late 1960s, studying microbiology on a fellowship at Catholic University of America. She and her husband had insurance as graduate students, but it excluded family coverage. Two of her five children were born with the assistance of a local community health clinic in Washington, and she paid the family pediatrician out of her own pocket.

Medical emergencies were especially harrowing. Nielsen recalls her frantic efforts in 1968 to get care when her 14-month-old daughter developed a fever of 105.6 degrees. On the advice of her doctor, Nielsen took the toddler to Children’s National Medical Center in Washington.

“It took almost every cent I had for the rest of the month,” Nielsen recalled. “It was the low point of my adult life.”

Nielsen said she sobbed with relief when her doctor asked a nurse to supply her with sample antibiotics, baby formula and diapers. “If he’d written a prescription, I couldn’t have filled it,” she said, “but I was too proud and too ashamed to tell him that.”

In view of that background, it’s not surprising that Nielsen devoted part of her inaugural speech as AMA president to a plea that the physicians’ lobby redouble its efforts to get health coverage for the uninsured.

It was also an unusual call to arms since for decades the AMA was all but synonymous with unyielding opposition to any plan to expand government health coverage. When President Harry S Truman proposed a national health system in the 1940s, physicians fought it, depicting the plan as socialized medicine. In the 1960s, the group recruited Ronald Reagan to record messages opposing a government-run health system. In the 1990s, when first lady Hillary Rodham Clinton proposed reforming the health system, the AMA’s Washington staff were initially receptive to the idea, but the organization’s leadership later turned against the efforts. The opposition stems from a simple question of dollars: Commercial insurers traditionally pay physicians at higher rates than federal entitlement programs such as Medicare do.

Lately, however, the AMA has softened its stance, as costs throughout the system continue to explode and more Americans go without coverage. The group has been taking part in efforts over the past several years to map out policies to broaden existing health coverage.

One strange-bedfellows coalition of 20 industry trade organizations and consumer groups the AMA participated in began meeting last year to lobby for more money for low-income children’s health coverage; the group recently reorganized in anticipation of a broader health reform debate next year, though the group still doesn’t have a name.

The AMA has a plan to expand coverage, mostly by extending government subsidies to low-income Americans and providing tax credits to buy health policies. But Nielsen said it is only a jumping-off point for future discussions. Physicians will probably always oppose a so-called single payer, in which all bills are paid by the government, but Nielsen said that as long as the efforts focus on a privately run system that’s devoid of anything resembling price controls, her organization would be open to a variety of approaches.

“The truth is there will be compromises,” she said. “If folks don’t like our plans, what’s theirs? We can’t just say, ‘We can’t, we can’t.’ ”

Other players in the health care debate say they welcome Nielsen’s policy of open engagement. Even during the Medicare fight, they note, she showed a penchant for flexibility that came through in small ways: At one point, she bucked some of her members by accepting a provision encouraging doctors to supply prescriptions in e-mail form, for the sake of maintaining momentum behind the broader bill. Older AMA physicians with minimal clerical or computer skills had urged the group to dig in against the provision.

“Nancy called me up and said, ‘Let’s try to get to the bottom of this,’ ” recalled Rother of AARP. “She took the initiative. She’s quite pragmatic and willing to take the larger view.”

The final version of the Medicare law still has the provision — but with language designed to give doctors more incentives and time to adjust. Doctors who use the technology would get bonus payments, starting at 2 percent in 2009 and declining to 0.5 percent by 2013. Doctors would be required to use e-prescribing by 2011; those who don’t use the technology will see their Medicare payments reduced by as much as 2 percent.

Nielsen also was involved in reaching consensus among health insurers, physicians, and New York Attorney General Andrew Cuomo on another ticklish question for the physicians’ lobby: The optimal way for health plans to rate the quality of care provided by physicians. Cuomo had been concerned that insurers were rating doctors based on how inexpensive their costs were. Nielsen provided input so insurers could set new standards, then allow independent groups to monitor their rankings.

Nielsen’s approach gives optimists some additional hope that the AMA will cooperate in plans to overhaul health care next year. Any significant health care initiative will face major challenges to becoming law no matter who is president, but advocates for change say they are pleased that the doctors lobby supports discussions about how to move forward.

Democratic Sen. Ron Wyden of Oregon says he has taken heart from the news that his home-state AMA affiliate has endorsed a health care bill he sponsored, which would break the traditional link between employment and insurance by requiring employers to pay higher wages in lieu of coverage. Under Wyden’s plan, employees would then be required to buy individual insurance policies in a regulated market in which insurers would be limited in their ability to deny coverage.

The Oregon medical society’s support was crucial in providing credibility for the measure, Wyden said.

“This is not your grandfather’s AMA,” Wyden said. “It was always, ‘Defend the status quo.’ There were just hobgoblins everywhere, and any effort to expand coverage really somehow got acquainted with the monster of socialized medicine.”

Meanwhile, Nielsen, who continues to serve as a senior associate dean at The University at Buffalo School of Medicine and Biomedical Sciences, is still pursuing smaller workable compromises, even at the profession’s retail level. Several weeks ago, she said she got an e-mail from a doctor with a patient who was in a private Medicare insurance plan. The Medicare patient was having trouble getting the insurer to pay for his cholesterol drugs.

Nielsen called the chief medical officer at the plan, telling him, “This shouldn’t happen.” Nielsen learned of the problem on a Saturday night and made the call over the weekend. By Monday evening, the patient had approval to get his drugs.

FOR FURTHER READING: Medicare doctor payment law (HR 6331 — PL 110-275), p. 1997; AARP position, p. 1516; background, p. 1595; Medicare drug law effect on employers, p. 1754; Balanced Budget Act (PL 105-33), 1997 Almanac, p. 2-27.